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MCCG240 – Evaluation Management Services Coding Scenario – Mock Exam Training 2 This Assessment combined with other assessments will be worth 15% of your overall grade. Deadline Due by the end of Week 4 at 11:59 pm, ET. Completing this Assessment will help you to meet the following: Course Outcome • Select the correct E/M codes and modifiers based on the documentation provided. Directions Imagine that you are a coding supervisor at a physician’s office and are requiring all of your coders to possess a coding credential, so you are asking all your coders to earn the American Health Information Association Certified Coding Specialist – Physician-based (AHIMA CCS-P) certification. To help your coders prepare for the certification exam, you decide to create a mock coding test to emulate what they might see on the exam. You have identified the patient records that your coders will work with on this mock test. Now, you need to create an answer key. 1. Review the following cases below or in Blackboard. a. Heather Morris b. Ashley Harper c. Wendell Polansky d. Kanon Thomas e. Margaret Denny MCCG240 Coding MCCG240 Coding MCCG240 Coding MCCG240 Coding MCCG240 Coding Scenario – OPOV59 Denny, Scenario Margaret.pdf – OPOV44 Thomas, Scenario Kanon.pdf – OPOV43 Polansky, ScenarioWendell.pdf – OPOV38 Harper, Scenario Ashley.pdf – OPOV28 Morris, Heather.pdf 2. Using your ICD-10 and CPT code books, identify which diagnoses, and E/M services, if any, are to be coded for each case. 3. Utilize the provided Coding Scenario Template for your answers. 4. For detailed grading information review the attached rubric to determine how your work will be graded and submit your work into Blackboard. MCCG240 – Coding Scenarios – Mock Exam Training 2 2 Coding Scenarios Template Criteria #038; Patients First Listed Diagnosis Secondary Diagnosis or Diagnoses E/M Procedure Heather Morris Ashley Harper Wendell Polansky Kanon Thomas Margaret Denny Coding Scenarios – Mock Exam Training 2 Criteria Accuracy of Coding Case Scenario 100 Points Instructor Comments: 3 MCCG240 – Grading Rubric Excellent Average Needs Improvement 90 – 100 points 70 – 89 points 0 – 69 points Assigned the correct codes in all five cases. Assigned the correct codes in four of the five cases. Assigned the correct codes in three or less of the five cases. Total Points: Points 10/12/21, 9:31 AM OPOV59DennyMargaret Outpatient Office Visit Patient Case Number: OPOV59-Denny, Margaret Patient Name: Margaret Denny DOB: 05-06-60 Sex: F Date of Service: 02-15-XX Physician: Robert Feldman, MD History of Present Illness: Mrs. Denny presents for a recheck of her Seizures. The seizures have been occurring for years. The seizures are usually followed by confusion, drowsiness, lethargy and weakness. The symptoms have been associated with a family history of epilepsy (patient’s mother) and hypertension. Patient states that she has been having headaches on the right back side of her head, and along with vertigo and heaviness in her right eye, ear pressure, and some cheek tightness. She has been seen by her PCP and has gone to the ER for these problems. She states that the vertigo has since gone away and that the other symptoms are intermittent. Follow-up MRI of the brain is completed and normal. This was independently reviewed. She is no longer experiencing the same intensity of the vertigo although she continues to have a sensation of pressure in the ear. Medical History: Epilepsy, htn, vertigo Medications: Lisinopril 10mg, 1 tablet daily, Tylenol Extra Strength 500mg tablet 2 oral prn, Lamictal 200mg oral two times daily Vitals: Temp-98.7, Pulse-70, Resp-17, BP 110/60, Height-5’6”, Weight-145lbs, BMI-23.4 Review of Systems General: Negative for chills, fatigue, fever, night sweats and weight Loss. Skin: Negative for excessive Sweating and Rash. HEENT: Negative for blurred vision, decreased hearing, difficulties with vision, diplopia, droopy eyelids, dysphagia, eye pain, hoarseness, nose bleeds, snoring and tinnitus. Neck: Negative for neck pain. Respiratory: Negative for apnea, cough and difficulty breathing. Cardiovascular: Negative for chest pain, edema, fainting, leg pain and/or swelling, palpitations and shortness of breath. Gastrointestinal: Negative for abdominal pain, nausea and vomiting. Musculoskeletal: Negative for back pain, joint pain, joint stiffness, joint swelling, leg crs, muscle crs, muscle weakness and restless legs. file:///C:/Users/smmeier/AppData/Local/Microsoft/Windows/INetCache/Content.Outlook/58GH39Y4/MCCG240 Coding Scenario – OPOV59 Denny Mar… 1/2 10/12/21, 9:31 AM OPOV59DennyMargaret Neurological: Negative for confusion, difficulty concentrating, difficulty falling asleep, difficulty walking, dizziness, dysarthria, excessive sleeping, fainting, falls, focal paralysis, focal weakness, headaches, loss of consciousness, memory loss, numbness, poor coordination, seizures, spinning sensation, syncope, tremor, tingling, transient blindness, unusual sensation, vertigo, visual changes and weakness. Psychiatric: Negative for anxiety, confusion, depression, hallucinations, inability to concentrate, mood changes and suicidal thoughts. Endocrine: Negative for cold intolerance and heat intolerance. Hematology: negative for abnormal bleeding and easy bruising. All other systems negative Assessment/Plan: 1. Non-intractable generalized idiopathic epilepsy w/o status epilepticus-well controlled on Lamictal 2. Vertigo-start new prescription for Antivert 3. Htn-continue on Lisinopril Electronically Signed By: Robert Feldman, MD Copyright © 2020 by The American Health Information Management Association. All Rights Reserved. file:///C:/Users/smmeier/AppData/Local/Microsoft/Windows/INetCache/Content.Outlook/58GH39Y4/MCCG240 Coding Scenario – OPOV59 Denny Mar… 2/2 10/12/21, 9:33 AM OPOV28MorrisHeather Outpatient Office Visit Patient Case Number: OPOV28-Morris, Heather (established pt) Patient Name: Heather Morris DOB: 05-16-65 Sex: F Date of Service: 11-01-XX Physician: Stanley Banks, MD Chief Complaint: “I feel like I am becoming my mother” History of Present Illness: Several weeks ago, the patient reports that she got very depressed again, was crying, and hardly functioning. Her sleep is still very poor, energy is low. Endorses a lot of PTSD symptoms, particularly when she has to have some kind of hospital procedure. Anything reminding her hospital is causing flashbacks, anxiety, and nightmares. She talks about how high functioning she used to be before her mother’s death. She even unable to complete disability paperwork without assistance of her husband. He helps with her depression some, but not much. She complains of tolerance, focus, and the inability to get things done. Medications: Klonopin 1.0 mg qhs, Xanax XR 0.5 mg prn, Acidophilus, digestive enzymes, Fexofenadine, Tylenol, Ventolin, Vit D 2000U Review of Systems Constitutional: low energy, fatigue. No appetite, she forces herself to eat. Ears, Nose, Mouth, Throat: recurrent staph infections, pharyngitis Genitourinary: 6 months ago, she started bleeding, had one bleed in September Musculoskeletal: weakness in her both legs, Gastrointestinal: no appetite. Now the problem is diarrhea, not constipation. Unable to leave house due to of diarrhea Skin/Breast: hair loss Psychiatric: as above Endocrine: started having hot flashes recently, after 3 years of menopause Hematologic/Lymphatic: very low Iron Mental Status Examination General appearance, orientation Alert, oriented, no signs of agitation/retardation. Eye contact is good. Comes on time. No make-up. Gait stable. Speech file:///C:/Users/smmeier/AppData/Local/Microsoft/Windows/INetCache/Content.Outlook/58GH39Y4/MCCG240 Coding Scenario – OPOV28 Morris Hea… 1/2 10/12/21, 9:33 AM OPOV28MorrisHeather clear, goal oriented, normal tone and amount Language function not affected Thought process/ content/ associations/ perceptual disturbance well organized, no signs of psychosis. Suicidal ideation Denies Judgement/ insight/ future orientation Fair Mood / affect mood is sad, affect is tearful Memory / attention / concentration Impaired Fund of knowledge Average Assessment: Axis I: MDD, recurrent, Anxiety, PTSD, chronic complicated 1bereavement, idiopathic hypersomnia Axis II: Deferred Axis III: Iron deficiency anemia Electronically Signed By: Stanley Banks, MD Copyright © 2020 by The American Health Information Management Association. All Rights Reserved. file:///C:/Users/smmeier/AppData/Local/Microsoft/Windows/INetCache/Content.Outlook/58GH39Y4/MCCG240 Coding Scenario – OPOV28 Morris Hea… 2/2 10/12/21, 9:33 AM OPOV38HarperAshley Outpatient Office Visit Patient Case Number: OPOV38-Harper, Ashley (established pt) Patient Name: Ashley Harper DOB: 08-09-78 Sex: F Date of Service: 09-16-XX Physician: Mark Shifter, MD Chief Complaint: Discharge and pus from eye History of Present Illness: Mrs. Harper presents for evaluation of discharge, pus. in the right eye and left eye. It occurs in the morning. The condition is stable. Pt states symptoms come and go every couple of months. Pt states vison seems fine today in both eyes and denies any pain. Pt complains of tired eyes and watery eyes. She has had DMII for about 4 years with an Alc of 7.3 last month. Does not check sugar. Past Ocular History: Patient notes no ocular history at this visit. Medical History: DM II Surgical History: Carpal tunnel release Social History: Noncontributory Medications: Metformin 500mg twice daily Review of Systems Ear, Nose, Mouth, Throat: Dry mouth Respiratory: Cough negative Integumentary: negative GI: negative Musculoskeletal: negative Cardio: negative Hema/Lymph: negative GU: negative Psych: negative Physical Examination: Patients mood/affects is normal. Patient is oriented to person, place, and time E xternal Examination file:///C:/Users/smmeier/AppData/Local/Microsoft/Windows/INetCache/Content.Outlook/58GH39Y4/MCCG240 Coding Scenario – OPOV38 Harper Ash… 1/3 10/12/21, 9:33 AM OPOV38HarperAshley Pupils: OD pupils equal, round, reactive, no APO OS pupils equal, round, reactive, no APD Confrontational Visual Fields: OD confrontation fields full to finger counting OS confrontation fields full to finger counting Motility: OD EOM is full OS EOM is full Adnexa: OD Adnexa is normal OS Adnexa is normal Eye Lids: OD lids and lashes are normal OS lids and lashes are normal Slit L Examination Conjunctiva: OD white and quiet OS white and quiet Cornea OD normal endothelial, epithelial, stroma and tear film OS normal endothelial, epithelial, stroma and tear film Iris OD iris is normal OS iris is normal Anterior Chamber OD anterior chamber is deep and quiet OS anterior chamber is deep and quiet Lens OS Clear lens capsule, cortex, and nucleus Assessment/Plan 1. Keratoconjunctivitis sicca of both eyes- Discussed diagnosis in detail with patient. Discussed treatment plan with patient. Educational materials provided for dry eye syndrome. Lotemax prescription provided. 2. DM II-continue Metformin Electronically Signed By: Mark Shifter, MD Copyright © 2020 by The American Health Information Management Association. All Rights Reserved. file:///C:/Users/smmeier/AppData/Local/Microsoft/Windows/INetCache/Content.Outlook/58GH39Y4/MCCG240 Coding Scenario – OPOV38 Harper Ash… 2/3 10/12/21, 9:33 AM OPOV38HarperAshley file:///C:/Users/smmeier/AppData/Local/Microsoft/Windows/INetCache/Content.Outlook/58GH39Y4/MCCG240 Coding Scenario – OPOV38 Harper Ash… 3/3 10/12/21, 9:32 AM OPOV43PolanskyWendell Outpatient Office Visit Patient Case Number: OPOV43-Polansky, Wendell Patient Name: Wendell Polansky DOB: 02-11-71 Sex: M Date of Service: 06-11-XX Physician: Juan Martinez, MD Chief Complaint: Lung mass History of Present Illness: The patient is an established patient and presents today with some back problems. He had a chest xray and a CT scan which showed azygos lobe which is a congenital anomaly without any consequence, but at the same time he was found to have multiple small nodules in the lung which were followed by Dr. Milly. For a while it had shown some slight increase, not so much in the nodules, but in the pretracheal area. The paratracheal lymph nodes on the PET scan showed significantly increased activity within these lymph nodes. The lung nodules had remained about the same size and had not increased in size. A couple of the lung nodules were calcified. The patient himself remains asymptomatic and has not had any cough with expectoration or hemoptysis and no weight loss. PFSH: As documented. I have reviewed and agree with prior documentation. Review of Systems General/Constitutional: denies recent weight loss, denies recent weight gain, denies fever, denies chills, denies change in exercise tolerance Integumentary: denies change in hair or nails, denies rashes, denies skin lesions Eyes: denies diplopia, denies visual field defects, denies blurred vision, denies eye pain, denies discharge Ears, Nose, Mouth, Throat: denies hearing loss, denies epistaxis, denies hoarseness, denies difficulty speaking Respiratory: snoring Cardiovascular: denies palpitations, denies chest pain, denies peripheral edema, denies syncope, denies claudication Gastrointestinal: denies ulcer disease, denies hematochezia and denies melena Genitourinary Male: non-contributory Musculoskeletal: reports back pain, arthritis Neurological: denies strokes, denies TIA, denies seizure disorder Psychiatric: reports depression Endocrine: denies heat/cold intolerance, denies polydipsia, denies polyuria Hematological/Immunologic: denies food allergies, denies seasonal allergies, denies bleeding disorders Sleep History: CPAP/BIPAP/VPAP/O2 recheck Medical History: Bipolar d/o, OSA, hyperlipidemia file:///C:/Users/smmeier/AppData/Local/Microsoft/Windows/INetCache/Content.Outlook/58GH39Y4/MCCG240 Coding Scenario – OPOV43 Polansky … 1/3 10/12/21, 9:32 AM OPOV43PolanskyWendell Medications: 1. Atenolol 25 mg Tablet 1 by mouth daily 2. Crestor 10 mg tablet 1 by mouth daily 3. Fenofibrate 160 mg tablet 1 by mouth daily 4. Fish Oil 1,000 mg Capsule 1 by mouth daily 5. Norco 5 mg-325 mg tablet as needed 6. Seroquel 200 mg Tablet 1 by mouth daily 7. Vitamin B Complex Tablet l by mouth daily 8. Aspirin Low Dose 81 mg tablet, delayed release 1 by mouth daily 9. Seroquel 200 mg Tablet 1 by mouth daily Surgical History: Arthroscopic knee sx, appendectomy Vital Signs: BP-118/78, Pulse-60, Weight-250lbs, Height-5’9”, O2 Sat-98%, BMI-36.9 Physical Examination Constitutional: cooperative, alert and oriented, well developed, well nourished, in no acute distress Skin: warm and dry to touch, no apparent skin lesions, no apparent masses noted Head: normocephalic, non-tender, no palpable masses Eyes: EOMS Intact, PERRL, conjunctivae and lids unremarkable ENT: ears unremarkable, throat clear, without erythema, good dentition Neck: no palpable masses or adenopathy, no thyromegaly, JVP normal, carotid pulses are full and equal bilaterally without bruits Chest: normal symmetry, no tenderness to palpation, normal respiratory excursion, no intercostal retraction, no use of accessory muscles, normal diaphragmatic excursion, clear to auscultation Cardiac: regular rhythm, Sl normal, S2 normal, no S3 or S4, apical impulse not displaced, no murmurs, no gallops, no rubs detected Abdomen: abdomen soft, bowel sounds normoactive, no masses, non-tender, no bruits Peripheral Pulses: femoral pulses are full and equal bilaterally with no bruits auscultated, popliteal pulses are full and equal bilaterally with no bruits auscultated, dorsalis pedis pulses are full and equal bilaterally with no bruits auscultated, posterior tibial pulses are full and equal bilaterally with no bruits auscultated Lymphatic: no lymphadenopathy Extremities #038; Back: no deformities, no clubbing, no cyanosis, no erythema, no edema, there are no spinal abnormalities noted, normal muscle strength and tone Psychiatric: appropriate mood, memory and judgment Neurological: no gross motor or sensory deficits noted Impression/Plan: 1. Enlarged lymph nodes (localized): I have discussed the findings with the patient and his wife and told them that we should consider a mediastinoscopy given the significantly increased activity within these lymph nodes to get a diagnosis. I discussed with them the risks of surgery, including file:///C:/Users/smmeier/AppData/Local/Microsoft/Windows/INetCache/Content.Outlook/58GH39Y4/MCCG240 Coding Scenario – OPOV43 Polansky … 2/3 10/12/21, 9:32 AM OPOV43PolanskyWendell risk of infection, and bleeding. The patient is agreeable and we shall schedule for surgery as soon as possible. 2. Bipolar d/o-continue Seroquel 3. Hyperlipidemia-continue fish oil and Fenofibrate 4. OSA-CPAP Electronically Signed By: Juan Martinez, MD Copyright © 2020 by The American Health Information Management Association. All Rights Reserved. file:///C:/Users/smmeier/AppData/Local/Microsoft/Windows/INetCache/Content.Outlook/58GH39Y4/MCCG240 Coding Scenario – OPOV43 Polansky … 3/3 10/12/21, 9:32 AM OPOV44ThomasKanon Outpatient Office Visit Patient Case Number: OPOV- Thomas, Kanon (New) Patient Name: Kanon Thomas DOB: 01-02-60 Sex: M Date of Service: 07-01-XX Physician: Richard Kelly, MD Chief Complaint: Needs to establish PCP. Dry cough x 5 months. Foot pain. History of Present Illness: Mr. Thomas is being seen for an initial evaluation of his cough which has been present on and off for about 2 years. Rarely productive but states sometimes white phlegm. In past he had been treated for both asthma and seasonal allergies but has been out of medication for quite some time now. Also states the cough is worse at night when laying down and often has a sore/rough throat in the morning Associated symptoms include dyspnea, wheezing, runny nose, heartburn and painful swallowing, but no chills, no fever, no stuffy nose, no sore throat, no myalgias, no pleuritic chest pain, no chest pain, no vomiting, no postnasal drainage, no mouth breathing, no rapid breathing, no hoarseness, no eye itching, no nose itching, no headache, no hemoptysis and no night sweats. Mr. Thomas also reports foot pain. He spends between 12-16 hours a day on his feet and has pain in both, R>L, for over a year now. Rest improves but weight bearing makes it worse. The pain is mainly in the heel area and is worst first thing in the morning with weight bearing. Ice helps to alleviate. Medical History: Asthma, GERD, seasonal allergies Allergy: NKDA Surgical History: Appendectomy Family History: • Family history of cardiac disorder • Family history of diabetes mellitus • Family history of hypertension • Family history of diabetes mellitus Medications: Flomax 0.4mg, Fluticasone 50 mcg/act, Myrbetriq 50mg, Naproxen 500mg, Omeprazole 20mg, Ventolin HFA 108 (90 base) mcg/act inhalation aerosol Review of Systems: Constitutional: no fever, no chills, no malaise and no fatigue. file:///C:/Users/smmeier/AppData/Local/Microsoft/Windows/INetCache/Content.Outlook/58GH39Y4/MCCG240 Coding Scenario – OPOV44 Thomas K… 1/2 10/12/21, 9:32 AM OPOV44ThomasKanon ENT: nasal congestion, sneezing, sore throat and scratchy throat, but no earache, no hearing loss, no nasal discharge and no hoarseness. Cardiovascular: negative. Respiratory: shortness of breath, wheezing and dry cough, but not sleeping upright or with extra pillows, no clear sputum, no colored sputum and no coughing up blood. Gastrointestinal: abdominal pain, nausea and reflux, but no abdominal bloating, no abdominal crs, no vomiting, no diarrhea, no hematemesis, no constipation and no bright red blood per rectum. Genitourinary: urinary frequency and nocturia, but no urinary urgency and no urinary incontinence. Musculoskeletal: diffuse joint pain, joint swelling and joint stiffness, but no generalized muscle aches, no back pain and no back muscle spasm. Vitals: Temp-98.7, HR 70, Resp-18, BP 128/38, Height 5’9”, Weight-215lbs, BMI-31.8 Physical Exam Constitutional General appearance: Abnormal. well developed, comfortable, well nourished, obese and rested. Ears, Nose, Mouth, and Throat: External inspection of ears and nose: Normal. Oropharynx: Normal. Nasal mucosa, septum, and turbinates: Normal. Pulmonary: Respiratory effort: Normal. Auscultation of lungs: Normal. Cardiovascular: Palpation of heart: Normal. Auscultation of heart: Normal. Examination of extremities for edema and/or varicosities: Normal. Abdomen: Normal. Liver and spleen: Normal. Musculoskeletal: Gait and station: Normal. Digits and nails: Normal. Inspection/palpation of joints, bones, and muscles: Normal. Skin: Skin and subcutaneous tissue: Normal. Neurologic Cranial nerves: Normal. Sensation: Normal. Psychiatric: Orientation to person, place, and time: Normal. Mood and affect: Normal. Assessment/Plan: 1. Mild intermittent asthma-start Ventolin HFA 108-inhale one puff every four hours as needed 2. Gastroesophageal reflux disease without esophagitis-start Omeprazole 20mg oral tablet, take one capsule daily as needed 3. Seasonal allergic rhinitis-start Fluticasone 50mcg/act, use one spray in each nostril once daily 4. Chronic foot pain, right-start Naproxen 500mg oral tablet, take one tablet every 12 hours as needed Electronically Signed By: Richard Kelly, MD Copyright © 2020 by The American Health Information Management Association. All Rights Reserved. file:///C:/Users/smmeier/AppData/Local/Microsoft/Windows/INetCache/Content.Outlook/58GH39Y4/MCCG240 Coding Scenario – OPOV44 Thomas K… 2/2
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